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HomeMy WebLinkAboutBLD-23-002787 , °, - Ca Iu� , 1/11er/�-� Office Use Only '; • ,.X aR'Ar . Permit# C.n?vl�' oedq l 0. C` Amount U,ad MA.iauto"ssc-. Permit expires 180 days from ::: •' 7�issue date ,{ (ter EXPRESS BUILDING PERMIT APPLICA ION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV 17 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 7....4.5 l_.,L3 Lr. \lK.%(-i‹... �-0 . c 1 �rl t-v-1 o k 1't l� ASSESSOR'S INFORMATION: Map: Parcel: OWNER: - -1 1sA J - tS_l'_t i Z4b '- ie V—c-3CAZ--- 5' yek a tvl .)TIP 50E, -Z94 -..56-4% NAME PRESENT ADDRESS TEL. # CONTRACTOR:C Pc cZ(cfe S &A vile- L t S k `J(r vd \-c'L.,\a vo, 1 .,Oh -3 6 7- 7 % NAME MAILING ADDRESS 5.*4 6.l,,l L, ..'rig— TEL.# Residential El Commercial Est.Cost of Construction$ 3 (, u / Home Improvement Contractor Lic.# l B©Co(D4- Construction Supervisor Lie.# C`S -- 0 RC ( s k Workman's Compensation Insurance: (check one) ❑ I am the homeowner lam the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent U Duration (Fire Retardant Certificate attached?) Wood Stove Li i1-. Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation I I I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing *The debris will be disposed of at: yA,fr-Vi c u\a 14 .LJ\ tom' "1/--- Location of Facility I declare under penalties of p 'ury at the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for deni o ation o my lice and for prosecution under M.G.L.Ch.268,Section 1. f ' ,t,kApplicant's Signature. Date: N/Cy 1/ /i \ Z-r 2 Owners Signature(or attachment) Z "( Date: !/�(�Z72-C) ?-,72-- Approved By: ' Date: /// Building Official esio EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No - Yes No The Commonwealth of Massachusetts lez IF Department of Industrial Accidents t et.= 1 Congress Street, Suite 100 _ ,,, Boston, MA 02114-2017 ww>�t.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): CAA or "Thi 1✓f pc./S Address: 15t V,/► C l iuc,� ' 17_,„ City/State/Zip: c- :/A R iNi(G Phone #: 5 k --3 4 7 - 6 7Z Are you an employer?Check the appropriate box: Type of project(required): 1.1:1I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.f am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. [I Demolition 10 ❑Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0Electrical repairs or additions proprietors with no employees. 12.®Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.DrOther .&-7, e L i 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: nef Job Site Address: 2.4 S « Zo. City/State/Zip: 5. t4 R two. -'L} Attach a copy of the workers' compensation policy declaration page(showing the policy num6er and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 'ZC5�ZZ Phone#: 5 3 (7 - ii 7 ?_.6 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons "ionr$ visor CS-080901 Eii CHARLES ESAMMON I� plres:01/25/2024 156 WITCH OD RD '"t _ • W SOUTH YARMJDUTH MA 0?664 . 1 Commissioner dj, /, /'.nL 0- 4.-' nfrt,�n izr��i`ffffL"�f�allr //� Office of airs s'fF-ieei gklation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 180664 12/10/2022 CHARLES Sl • it s:.... .i• 1- CHARLES E.SIMMO.. Y 156 WITCHWOODRD SOUTH YARMOUTh MA 02664 Undersecretary